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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 130-137

Surgical and functional outcomes of infective non union of femur and tibia using ilizarov ring fixator


1 Professor, Department of Orthopaedics, Smt BK Shah Medical Institute & Research Centre, Sumandeep Vidyapeeth Deemed to be University, Waghodia, Vadodara 391 760, Gujarat, India
2 Professor Department of Orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Shivaji Nagar, Pune 411 005, Maharashtra, India
3 Senior Resident, Department of Orthopaedics, Smt BK Shah Medical Institute & Research Centre, Sumandeep Vidyapeeth Deemed to be University, Waghodia, Vadodara 391 760, Gujarat, India
4 Third Year PG Resident, Department of Orthopaedics, Smt BK Shah Medical Institute & Research Centre, Sumandeep Vidyapeeth Deemed to be University, Waghodia, Vadodara 391 760, Gujarat, India
5 Second Year PG Resident, Department of Orthopaedics, Smt BK Shah Medical Institute & Research Centre, Sumandeep Vidyapeeth Deemed to be University, Waghodia, Vadodara 391 760, Gujarat, India
6 Dean & Professor, Smt BK Shah Medical Institute & Research Centre, Sumandeep Vidyapeeth Deemed to be University, Waghodia, Vadodar, India

Date of Submission08-Oct-2022
Date of Decision04-Dec-2022
Date of Acceptance12-Dec-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Aditya K Agrawal
Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth (Deemed to be University), Waghodia, Vadodara - 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jllr.jllr_31_22

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  Abstract 


Introduction: Nonunion of long bone fractures is a common condition encountered by an orthopedic surgeon in daily practice. For effective treatment of nonunion, internal fixation with or without bone grafting can be done but, an infected non union can prove to be a tough challenge. The aim of our study is to assess the surgical and functional outcomes of infected nonunion of femur and tibia treated with debridement, corticotomy and Ilizarov ring fixator. Materials and Method: This was a multi-centric prospective study of twenty patients in a time span of three years from May 2017 till April 2020. Observations and Results: Patients were assessed using clinical and functional results as per Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System. Conclusion: The Ilizarov method remains one of the most successful and versatile means of achieving bone-healing in infected nonunion of long bones of lower limbs with benefits of correcting deformities, bone defects and limb length discrepancy.

Keywords: Ilizarov, Infected non union, Tibia, Femur, ASAMI


How to cite this article:
Agrawal AK, Puram CP, Mutha YM, Mehta VJ, Arora S, Golwala P. Surgical and functional outcomes of infective non union of femur and tibia using ilizarov ring fixator. J Limb Lengthen Reconstr 2022;8:130-7

How to cite this URL:
Agrawal AK, Puram CP, Mutha YM, Mehta VJ, Arora S, Golwala P. Surgical and functional outcomes of infective non union of femur and tibia using ilizarov ring fixator. J Limb Lengthen Reconstr [serial online] 2022 [cited 2023 Jan 29];8:130-7. Available from: https://www.jlimblengthrecon.org/text.asp?2022/8/2/130/366306




  Introduction Top


Infected nonunion of fractures is one of the difficult surgeries in orthopedics due to presence of deformity, bone loss or malfunction of previous internal fixation. The Ilizarov technique is a good method and offers satisfactory solution for infected nonunion.[1],[2]

Bone and soft-tissue regeneration occurs under tensile forces in Ilizarov treatment technique and this is called the theory of tension stress.[3],[4] Distraction osteogenesis is slow, controlled and gradual stretching of the callus to fill the bony gap after corticotomy.[5] To eliminate infection and obtain union, vascularity must be increased for ilizarov to be effective.

The Ilizarov technique allows compression, lengthening, distraction, and correction of deformity along with the filling of bone defect. The frame stability allows immediate weight bearing and mobilization of joints.[6] One of the major risk of infected nonunion is amputation of the limb, and the Ilizarov technique has proven to reduce this possible consequence. The disadvantages are that it is cumbersome, difficulty in dressings of the wounds and needs expertise. Patients must be cooperative and must understand the longetivity of the treatment frame and meticulous follow-up.[6],[7],[8],[9]

Aim and objectives

Aim

To assess the clinical and functional outcome management of infected nonunion of long bones of the lower limb using Ilizarov fixator.

Objectives

  • To eradicate infection and achieve bony union while maintaining length and alignment of the limb with correction of old deformities
  • Prevention of appearance of new deformities
  • Early mobilization and weight bearing to prevent disuse atrophy of the muscles of the limb.


The results were analyzed using the radiological and functional results and application of methods of Ilizarov (Association for the Study and Application of Methods of Ilizarov [ASAMI]) scoring system.[8]

Inclusion criteria

Twenty adult patients who reported with an infected fracture nonunion of tibia or femur to our hospital between May 01st, 2017 and April 30th, 2020 were included in this study.

Exclusion criteria

  • Patients <18 years of age
  • Patients presenting with noninfected nonunion
  • Pathological fractures
  • Patients not willing to participate in the study.



  Materials and Methods Top


This prospective multicentric study was conducted on 20 patients in a time span of 3 years. After admitting the patient, careful history was recorded followed by clinical examination. Preoperative radiological evaluation was done [Figure 1] to determine the plane of deformity, assess alignment, classify nonunion, and to look for signs of active infection or osteomyelitis.
Figure 1: Preoperative radiograph of right proximal tibia non-union

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Operative management

After taking written and informed consent and preanesthetic checkup, all the internal (interlocking nail, screw or plates) or external fixation implants applied prior were removed and slab was given. In infected case, pus was sent for culture and sensitivity. Sinogram was done wherever required. Dressing was done on alternate day for 14 days and antibiotics were given based on culture sensitivity report. Once infection subsided, the patient was taken for operative management.

In infected case, debridement of the nonunion site was done along with refreshening of the bone edges and opening the medullary canal. An autoclaved preconstruct frame was used. The number of rings to be used was decided preoperatively based on the fracture site and site of corticotomy. The proximal and distal most rings were kept parallel to knee and ankle joint line [Figure 2] and [Figure 3].
Figure 2: Immediate postoperative radiographs AP view

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Figure 3: Immediate postoperative radiographs lateral view

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For cortical bone, bayonet tip wires were used and for cancellous bone, trocar tip wires were used. The wires were first passed proximally fixing proximal ring to the limb. With the help of dynamometric tensioner, appropriate tensioning was done. Then, the distal most wires were applied to the limb just proximal to the distal joint. Thereafter preconstruct frame was applied in between the proximal and the distal most wires. Tensioning was done in all wires. Schanz pin if required was applied with the posts [Figure 4] and [Figure 5].
Figure 4: Ilizarov ring frame

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Figure 5: Postoperative radiograph at 3 months showing corticotomy site

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The level and number of corticotomy was decided based on the site and gap of the nonunion site preoperatively [Figure 6].
Figure 6: Postoperative radiograph at 7 months showing healing at corticotomy site

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Postoperative management

It was divided into early and late treatment. Distal neurovascular status was checked and documented. The wire-skin surface was protected with a piece of gauze soaked in povidone iodine. Noncircular bandages were applied to the incisions. Limb was kept elevated. Intravenous antibiotics were given for 3 days followed by oral for the next 10 days. Daily dressing was done with povidone iodine. Active and passive mobilization of knee and ankle movement was started on the same day after anesthesia effect wears off. On the 2nd postoperative day, partial weight bearing was started, postoperative X-rays were done.

Follow up treatment

The wires must be checked to assure that they remain tight. If not, they were retensioned. The nuts and clamps were also being checked for tightness. Regular pin tract dressing was done and if infection occurred, the oral antibiotics were restarted. The rate of distraction and compression changed was based on the radiographic evaluation of the quality of regenerating bone. The apparatus was left in place until radiologic consolidation and union at the fracture nonunion site. Physiotherapy continued throughout the period [Figure 7].
Figure 7: Radiograph after ilizarov frame removal after 1 year

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Removal of apparatus

When the patient was able to walk without pain and X-rays suggested union of nonunion site as well as corticotomy site, the nuts of the threaded rods were unscrewed and patient was allowed to walk and asked to return back in 2 weeks. If there was no discomfort with weight bearing, the apparatus was removed [Figure 8].
Figure 8: Preoperative radiograph of open Grade III B lower third femur fracture treated with external fixator elsewhere

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On an average, the frame was kept at least twice the period of distraction for consolidation to occur at the corticotomy site. All the patients were in regular follow-up in our out-patient department in this study and the results are evaluated on the basis of ASAMI scoring system for bony healing and function.


  Results Top


During the study period, 20 patients were selected for the inclusion in the study. The age range of the patients in the study was 18–60 years with a mean of 36.5 years. All patients were from the rural areas and they were mostly farmers or daily laborers and so the study population was considered as rural. Of the 20 patients, 8 (40%) were in the age group of 18–30 years, 7 patients (35%) were in age group of 31–50 years and remaining 5 patients (25%) were in age group of 51–60 years. Seventeen patients (85%) were male and 3 patients (15%) were female. It was observed in the study that 14 patients (70%) of cases, the right leg was involved. The most common mode of injury was road traffic accident. Sixteen patients (80%) suffered road traffic accident and 4 patients (20%) fell from height. All were medicolegal cases, with first information report registered. Fourteen patients (70%) patients were operated for tibia nonunion and 6 patients were operated for femur nonunion [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]. For tibia, the most common site of infected nonunion was proximal third (n = 6) followed by lower third (n = 5) and middle third (n = 3). For femur, the most common site of infected nonunion was lower third (n = 4) followed by middle third (n = 2). At the time of initial injury, 15 patients (75% cases) suffered open fracture and were primarily treated elsewhere with external fixator device (AO clamps and rods) and 5 patients (25%) had closed fracture which were treated initially elsewhere with open reduction and internal fixation with plate. Out of 20 patients, 3 patients had associated injuries. Two patient had ipsilateral shaft femur fracture treated with femur interlock nail and 1 patient had shaft tibia fracture treated with tibia interlock nail. The most common deformity was varus deformity (11° ± 3°) of shaft femur as well as shaft tibia (20° ± 7°) along with crepitus at the fracture site. The deformity was less in patients with intra medullary implants as compared to extra medullary implant fixation. The patients were not able to do straight leg raising, unable to stand on affected leg and unable to walk full weight bearing due to infected nonunion of the affected leg. On radiological examination, Centre of Rotation Axis was determined using mechanical axis and anatomical axis for preoperative evaluation of the deformity for its subsequent correction.
Figure 9: Immediate postoperative radiographs of ilizarov frame fixation for lower third femur infective nonunion

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Figure 10: Completely healed femur nonunion after 10 months of ilizarov frame

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Figure 11: Open Grade III B lower third tibia fracture treated initially with debridement and external fixator

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Figure 12: Infective nonunion of lower third tibia fracture

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Figure 13: Immediate postoperative radiographs of ilizarov frame fixation for lower third tibia infective non union

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Figure 14: Completely healed tibia nonunion after 10 months of ilizarov frame

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Figure 15: Clinical radiograph of the patient of single leg stance on affected side

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All the patients (100%) had infected nonunion before undergoing Ilizarov procedure. Out of 20 patients, no organisms but plenty of pus cells were detected in 7 patients (35%). Out of the remaining 13 patients, most common organism isolated was Staphylococcous aureus (n = 7, 53.8%),  Escherichia More Details coli (n = 4, 30.8%), Klebsiella pneumonie (n = 1, 7.7%) and  Proteus mirabilis Scientific Name Search  (n =1, 7.7%). Antibiotics were started based on culture sensitivity and minimum inhibitory concentration. Most common antibiotic started were a combination of intravenous Linezolide and Clindamycin for 3 weeks followed by oral formation of the same antibiotics. Mean number of operations done in all patients before Ilizarov procedure was 2.55. During operation, the fracture site was debrided with necrectomy, refreshening of bone edges and opening the sclerotic margins of the medullary canal. The bone gap range was between 1 and 5 cm and the mean being 2.8 cm. Lengthening at the corticotomy site by the principles of distraction osteogenesis with bone transport was done in 11 cases (55%). The other nine cases required compression at the fracture site. The Ilizarov fixator was kept for an average period of 184.32 days, the range being 170–300 days. Follow-up was done following removal of fixator. The mean duration of follow-up was 8.8 months, the range being 3–18 months. Lengthening achieved ranged from 15 to 50 mm, mean being 26.9 mm [Table 1].
Table 1: Demographic profile and Association for the Study and Application of Methods of Ilizarov score of 20 patients at final follow-up

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Nonunion healed in 19 out of 20 patients (95%). Remaining 1 patient required secondary surgery in form of Expert tibia nail for proximal tibia nonunion. Mean number of days in hospital for each patient was 24 days (12–50). The average bone gap before debridement was 2.13 cm (range 1–4 cm) and after thorough debridement with refreshening of the bone ends was 5.43 cm (range 3–8 cm). The time to union was defined as the time from application to the removal of Ilizarov frame. This was 214.03 days (range 136–320 days) or 7.05 months. The average residual limb shortening after the removal of fixator was noted as 0.55 cm (Range 0–1.5 cm).

Out of 20 patients, 11 patients underwent three surgeries for treatment using ilizarov frame fixation, corticotomy and frame removal. Eight patients underwent four surgeries including realignment of the frame. One patient underwent five surgeries including redebridement and internal fixation after frame removal. The ring fixator was removed after union was confirmed both clinically and radiologically. It was followed by plaster cast application for 3 months. Patients were encouraged to walk full weight bearing on plaster cast. As per ASAMI bony and functional scoring system, 9 patients had excellent results, 8 patients had good results, 2 patients had fair outcomes, and 1 patient had poor outcome. The average residual limb shortening after removal of fixator was noted as 0.55 cm (Range 0–1.5 cm). Out of 20 patients, 6 patients (30%) had postoperative complications in form of 2 patients had stiff knee, 1 patient had stiff ankle, 2 patients acquired pin site infection and were successfully treated with pin tract care and oral antibiotics. In 1 patient, wire breakage was encountered which was addressed with rewire fixation. Nineteen patients were able to return to their previous routine as well as professional activities. One patient had to switch to desk job due to limp and residual shortening. One patient developed reflex sympathetic dystrophy for which conservative treatment in the form of opoids and nerve rejuvenators was given. None of the patients required or demanded amputation at the final follow-up.


  Discussion Top


The basic principles of the Ilizarov method is stable fixation, a low energy osteotomy with gradual distraction and bone formation by intramembranous ossification.[10] The options for treatment in an established infected bony nonunion are thorough debridement along with skeletal stabilization, using of antibiotic coated nail, use of antibiotic beads along with nail/plate, use of vascularized grafts, open cancellous bone grafting, use of an antibiotic impregnated, osteoconductive, bioabsorbable bone substitute, use of ring/rail fixator.[11]

The application of the methods of Ilizarov including compression-distraction osteosynthesis offer alternatives to the standard treatment of infected nonunion. Ilizarov circular frame osteosynthesis allows resection of the infected bone area, repair of the bone defect and stabilization of the bone to consolidation, while maintaining or restoring the length of the limb as desired.[12] Joint function in the involved extremity is encouraged during the period the apparatus must be worn and functional loading can be initiated within the first few days after application of the apparatus.[13]

The aim of a successful Ilizarov treatment for nonunion is not just to achieve healing of the nonunion, it is also to achieve a leg without deformities, shortening or infection with a normal range of motion and normal strength of bone and soft tissues. The Ilizarov frame construct is very resistant to torsion and bending forces but is adaptable to axial loading.[14]

In studies of Green et al.,[8] the largest number of complications was associated with wire tract infection whereas the second biggest difficulty was wire loosening associated with infection or osteolysis. In our study, 2 patients have superficial wire tract infection treated with dressing and oral antibiotics. Jain and Sinha[15] in their study of infected nonunion, suggested that distraction histiogenesis is the preferred procedure in nonunion with active or quiescent infection and a bone gap of 4 cm or more.

Although we had small sample size with short duration follow-up, we found nine patients (45%) had excellent results as per ASAMI score. This is comparable with various studies in the literature like Krishnan et al. and Yin et al. had 15% and 37% excellent result respectively.[16],[17] The treatment of infected nonunion in the elderly is even more challenging in view of reduced physiological reserve, presence of osteopenia/osteoporosis, reduced healing capabilities.[18],[19],[20] The capability to bear weight is an enormous benefit to the older population, where recumbence has a negative impact on the overall physiology and can escalate the risk of thrombo embolic disease and infections.[21],[22] The main limitation of the study was our small sample size and short duration of follow-up. Furthermore studies with longer duration of follow-up will be required in the future to validate our results.


  Conclusion Top


Infected nonunion pose a daunting challenge to both patient and surgeon and the Ilizarov technique has been successful in their management. It was found that Ilizarov ring fixator still remains an excellent treatment modality for tibial nonunion with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ring D, Jupiter JB, Gan BS, Israeli R, Yaremchuk MJ. Infected non union of the tibia. Clin Orthop Relat Res 1999;369:302-11.  Back to cited text no. 1
    
2.
Ilizarov GA, Deviatov AA, Trokhova VG. Surgical lengthening of the shortened lower extremities. Vestn Khir Im I I Grek 1972;108:100-3.  Back to cited text no. 2
    
3.
Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959-66.  Back to cited text no. 3
    
4.
El-Rosasy MA. Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia. J Bone Joint Surg Br 2007;89:80-8.  Back to cited text no. 4
    
5.
McKee MD, DiPasquale DJ, Wild LM, Stephen DJ, Kreder HJ, Schemitsch EH. The effect of smoking on clinical outcome and complication rates following Ilizarov reconstruction. J Orthop Trauma 2003;17:663-7.  Back to cited text no. 5
    
6.
Madhusudhan TR, Ramesh B, Manjunath K, Shah HM, Sundaresh DC, Krishnappa N. Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions – A prospective study. J Trauma Manage Outcomes 2008;2:6.  Back to cited text no. 6
    
7.
Dhar SA, Mir MR, Ahmed MS, Afzal S, Butt MF, Badoo AR, et al. Acute peg in hole docking in the management of infected non-union of long bones. Int Orthop 2008;32:559-66.  Back to cited text no. 7
    
8.
Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management of segmental defects by the Ilizarov intercalary bone transport method. Clin Orthop Relat Res 1992;280:136-42.  Back to cited text no. 8
    
9.
Shortt NL, Keenan GF, Muir AY, Simpson AH. The use of a nerve stimulator to allow safe placement of Ilizarov wires. Oper Orthop Traumatol 2006;18:364-76.  Back to cited text no. 9
    
10.
de Pablos J, Barrios C, Alfaro C, Cañadell J. Large experimental segmental bone defects treated by bone transportation with monolateral external distractors. Clin Orthop Relat Res 1994;298:259-65.  Back to cited text no. 10
    
11.
Thonse R, Conway J. Antibiotic cement-coated interlocking nail for the treatment of infected nonunions and segmental bone defects. J Orthop Trauma 2007;21:258-68.  Back to cited text no. 11
    
12.
McKee MD, Wild LM, Schemitsch EH, Waddell JP. The use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: Early results of a prospective trial. J Orthop Trauma 2002;16:622-7.  Back to cited text no. 12
    
13.
Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: A report of 24 cases. J Orthop Trauma 2004;18:150-7.  Back to cited text no. 13
    
14.
Arora S, Batra S, Gupta V, Goyal A. Distraction osteogenesis using a monolateral external fixator for infected non-union of the femur with bone loss. J Orthop Surg (Hong Kong) 2012;20:185-90.  Back to cited text no. 14
    
15.
Jain AK, Sinha S. Infected nonunion of the long bones. Clin Orthop Relat Res 2005;3:57-65.  Back to cited text no. 15
    
16.
Krishnan A, Pamecha C, Patwa JJ. Modified Ilizarov technique for infected nonunion of the femur: The principle of distraction-compression osteogenesis. J Orthop Surg (Hong Kong) 2006;14:265-72.  Back to cited text no. 16
    
17.
Yin P, Zhang L, Li T, Zhang L, Wang G, Li J, et al. Infected nonunion of tibia and femur treated by bone transport. J Orthop Surg Res 2015;10:49.  Back to cited text no. 17
    
18.
Zhang H, Xue F, Jun Xiao H. Ilizarov method in combination with autologous mesenchymal stem cells from iliac crest shows improved outcome in tibial non-union. Saudi J Biol Sci 2018;25:819-25.  Back to cited text no. 18
    
19.
Peng J, Min L, Xiang Z, Huang F, Tu C, Zhang H. Ilizarov bone transport combined with antibiotic cement spacer for infected tibial nonunion. Int J Clin Exp Med 2015;8:10058-65.  Back to cited text no. 19
    
20.
Abuomira IE, Sala F, Elbatrawy Y, Lovisetti G, Alati S, Capitani D. Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame. Strategies Trauma Limb Reconstr 2016;11:153-9.  Back to cited text no. 20
    
21.
Khan MS, Rashid H, Umer M, Qadir I, Hafeez K, Iqbal A. Salvage of infected non-union of the tibia with an Ilizarov ring fixator. J Orthop Surg (Hong Kong) 2015;23:52-5.  Back to cited text no. 21
    
22.
Eralp İL, Kocaoğlu M, Dikmen G, Azam ME, Balcı Hİ, Bilen FE. Treatment of infected nonunion of the juxta-Articular region of the distal tibia. Acta Orthop Traumatol Turc 2016;50:139-46.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
    Tables

  [Table 1]



 

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